Case #11
A 20-year-old female presented to the dental office for a routine check-up. At the time of the appointment, a swollen upper lip was noted.
Joen Iannucci Haring, DDS, MS
History
When questioned about the swollen upper lip, the patient stated that it had first appeared the day before with a rapid onset. The patient described the area as painless and denied any history of injury to the area. The patient`s last dental visit had taken place one year earlier.
At the time of the dental appointment, the patient appeared to be in an overall good state of health. The patient reported a recent visit to her physician for strep throat. At the time of the examination, the patient was finishing a penicillin prescription for the treatment of the strep throat.
Examinations
Physical examination of the head and neck region revealed no abnormal findings. The patient`s vital signs were all found to be within normal limits. No unusual or abnormal extraoral findings were noted. Oral examination revealed a diffuse non-tender enlargement of the upper lip (see photo). No evidence of erosion or ulceration was noted. Further oral examination revealed no other lesions present.
Clinical diagnosis
Based on the clinical information presented, which of the following is the most likely clinical diagnosis?
X- Nasolabial cyst
X- Angiodema
X- Cheilitis glandularis
X- Cheilitis granulomatosa
X- Factitious cheilitis
Diagnosis
Angioedema
Discussion
Angioedema can be described as an allergic reaction that involves the rapid swelling of the lips and adjacent structures. Angioedema occurs in susceptible patients after contact with an allergen, certain medications, or exposure to the elements. There are two types of angioedema - acquired and hereditary.
Acquired angioedema is the most common type and frequently is the result of the ingestion of a medication. Most of the acquired types are IgE immune-mediated, especially those initiated by penicillin. In addition, patients taking drugs such as aspirin, indomethacin, captopril, and enalaprilate may also experience angioedema. In other patients, angioedema may occur after physical stimuli, including exposure to sun, heat, or cold, as well as exercise and emotional stress. Contact allergic reactions from foods, cosmetics, and topical medications may also be implicated in acquired angioedema.
Hereditary angioedema is a rare condition that may involve the respiratory and gastrointestinal systems and is potentially life-threatening. Involvement of these systems may result in a medical emergency due to intense pain, vomiting, and laryngeal constriction. In this form, the swelling occurs after mild trauma to the area. Prevention of such trauma is essential in avoiding acute attacks. In patients diagnosed with hereditary angioedema, prophylaxis with androgenic drugs is required prior to dental and surgical procedures.
Clinical features
Acquired angioedema is an acute condition that is characterized by a rapid onset occurring over a period of hours. This condition presents as a soft-tissue swelling that involves the lips, buccal mucosa, or tongue. When the lips are involved, the swelling usually is uniform and diffuse. Other sites of involvement may include the face, hands, and arms. The symptoms most often associated with angioedema are burning and itching. Erythema may be present. Pain typically is not a feature. Acquired angioedema is usually recurrent and self-limiting.
Diagnosis and treatment
The diagnosis of angioedema is established based on the clinical presentation and the identification of a precipitating allergen. A good history is essential. Patients should be asked about the use of medications and cosmetics, as well as the ingestion of potentially allergenic foods (nuts, berries, or shellfish, for example). In addition, questions should be asked concerning the history of physical stimuli, including exposure to sun, heat, or cold, as well as exercise and emotional stress. In cases where multiple allergens are identified, antigenic testing may be required. In a patient without a history of antigenic exposure, hereditary angioedema must be considered, and the patient must be evaluated for a C1-UNH deficiently.
When acquired angioedema is suspected, the patient should be advised to discontinue the use of the potential allergen. Following the discontinuation of the product, the swelling should resolve in 24 to 72 hours. Antihistamines may be used to lessen the severity of the symptoms.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.
